What is the appropriate post-fall assessment and management for a nursing home resident?

Post-Fall Assessment for Nursing Home Residents

Conduct a comprehensive post-fall assessment within 7 days of the fall, develop an individualized treatment plan with specific interventions, educate staff on implementation, and refer to the primary physician for medical optimization—this approach reduces both subsequent falls and hospital admissions. 1

Immediate Post-Fall Assessment Components

Medical Evaluation

• Obtain detailed fall circumstances: exact location, time spent on floor, presence of loss of consciousness, altered mental status, symptoms of near-syncope or orthostatic hypotension 2
• Perform head-to-toe examination to identify occult injuries, with particular attention to head trauma, fractures, and soft tissue injuries 2
• Measure orthostatic vital signs: assess blood pressure and heart rate supine, sitting, and standing to identify postural hypotension—a priority target for fall prevention 3, 2
• Complete neurological assessment focusing on neuropathies, proximal muscle strength, gait abnormalities, and balance deficits 2, 4

Functional Assessment

• Evaluate gait and balance through direct observation and the "get up and go test"—residents unable to rise from bed, turn, and steadily ambulate require immediate intervention 2, 4
• Assess transfer ability: observe sit-to-stand, bed mobility, and wheelchair transfers, as 82% of falls in nonambulatory residents occur during transferring 5
• Document mobility status: distinguish between ambulatory, nonambulatory with transfer capacity, and bed-bound residents, as risk factors and prevention strategies differ substantially 5

Environmental and Equipment Review

• Inspect assistive devices: check walkers, canes, wheelchairs for proper fit, function, and safe use 6, 4
• Evaluate equipment safety: 87% of falls in nonambulatory residents involve equipment, particularly during transfers from chairs or beds 5
• Assess immediate environment: identify hazards in the resident's room and common areas 6

Diagnostic Testing

Order the following tests based on clinical presentation:

• EKG if cardiac symptoms, syncope, or unexplained fall 2
• Complete blood count and electrolyte panel to identify metabolic derangements 2
• Medication levels when applicable (digoxin, anticonvulsants) 2
• Imaging if trauma suspected (head CT for altered mental status, radiographs for suspected fractures) 2
• DEXA scan with vitamin D, calcium, and PTH levels to evaluate fracture risk and osteoporosis 2

Medication Review (Critical Component)

Conduct comprehensive medication assessment with mandatory physician referral for optimization: 1, 3

• Identify high-risk medications: vasodilators, diuretics, antipsychotics, sedative/hypnotics—all show consistent association with falls 3, 6
• Flag polypharmacy: ≥4 medications significantly increases fall risk regardless of drug class 3, 2
• Review psychotropic drugs: both long- and short-acting benzodiazepines carry equal fall risk and should be targeted for reduction 3, 4
• Refer to primary physician for medication adjustment—this is mandatory, as education without referral does NOT reduce falls 3, 2

Development of Individualized Treatment Plan

Physical Therapy Referral (Evidence-Based Interventions)

• Prescribe balance training 3 or more days per week for at-risk residents 3, 2
• Implement strength training twice weekly targeting lower extremity strength, range of motion, and transfer ability 3, 2
• Provide gait assessment and training with focus on safe ambulation techniques 6, 4

Important caveat: Non-selective exercise programs for all nursing home residents do NOT reduce falls—only targeted interventions for high-risk residents are effective 1

Occupational Therapy Referral

• Arrange home safety evaluation with direct intervention, advice, and education—not just assessment alone 1, 3, 2
• Optimize assistive device use through hands-on training and proper fitting 6, 4
• Modify environment to reduce specific hazards identified during assessment 6, 4

Medical Interventions

• Treat postural hypotension aggressively—this is a priority target with strong evidence for fall reduction 3, 2
• Prescribe vitamin D 800 IU daily for residents at increased fall risk 3, 2
• Address cardiovascular disorders and visual problems identified during assessment 3, 2

Hip Protector Implementation

• Offer hip protectors to all nursing home residents—while they don't reduce fall rates, they prevent hip fractures when worn during falls 1, 6
• Address compliance proactively: compliance is a known problem, so implement strategies to encourage consistent use 1

Staff Education (Essential Component)

Educate nursing staff on the specific treatment plan within 7 days of the fall—this combined approach of assessment, individualized planning, and staff education decreases subsequent falls: 1

• Train staff on resident-specific risk factors and interventions 1, 6
• Review proper transfer techniques and equipment use 6, 5
• Emphasize monitoring protocols for high-risk residents 6, 4

Follow-Up Requirements

• Schedule reassessment to evaluate intervention effectiveness and adjust plan as needed 3, 2
• Monitor for recurrent falls: residents with one fall have significantly increased risk for subsequent falls 3, 2
• Refer to bone health clinic if osteoporosis identified on DEXA scan 2
• Arrange multidisciplinary follow-up for high-risk residents with multiple falls or complex medical issues 2, 6

Critical Pitfalls to Avoid

• Do not implement education and assessment without referral—this approach has Grade A evidence showing it does NOT reduce falls 3, 2
• Avoid non-selective exercise programs—these are ineffective in nursing home populations 1
• Do not use physical restraints—these cause more harm than benefit and should be avoided 4
• Do not delay assessment beyond 7 days—early intervention within one week reduces hospital admissions and fall recurrence 1